Cryotherapy, also known as Cryosurgery is the application of extreme cold to treat or destroy keloids. Cryotherapy utilizes liquid nitrogen to induce precise frostbite inside a keloid lesion. About 80% of the air we breathe is made of nitrogen, an inert gas that does not react with other chemical elements. Under extreme pressure, gases transform shape and become liquid; upon evaporation, liquid nitrogen produces extreme cold, -196 Celsius (-320 Fahrenheit).

Cryotherapy is the most effective, the most economical and the safest method of treating bulky keloids. See "Cryotherapy in the treatment of keloids."
Like most other medical procedures, the success of this treatment is purely operator dependent. The expertise of physicians using this method is the most critical factor in achieving desired results from cryotherapy

A common mistake in applying cryotherapy to a keloid is assuming that one can simply spray liquid nitrogen on the keloid by using a liquid nitrogen spray gun. This method of cryotherapy is highly ineffective. Although using a spray gun application may cause the surface of a keloid to appear frozen, quite often, the deep tissue remains untreated. As a result, the treatment does not achieve desired results and also causes the patient pain and discomfort. Worse yet, the treating physician concludes that the cryotherapy treatment was ineffective.

Having treated over 1,000 keloid patients - mostly with cryotherapy - Dr. Tirgan has developed a unique method of applying cryotherapy, which allows for successful removal of most bulky keloid lesions. For instance, nearly all ear keloids can be successfully removed, with quite a low recurrence, when cryotherapy is applied correctly. Bulky keloids that are located elsewhere on the body can also be successfully removed with proper cryotherapy.

In freezing keloids, physicians must consider the location, shape, and size of a keloid. Every patient poses a unique challenge; therefore, a careful cryotherapy plan has to be devised for each patient and each keloid lesions.

Before initiating cryotherapy, several factors have to be taken into consideration. Application of cryotherapy can be uncomfortable and at times painful. Furthermore, everyone has a different pain tolerance, and each segment of skin has its unique sensitivity to pain. The constellation of all these variables calls for an individualized cryotherapy plan designed to meet patients’ unique needs; an art mastered only through experience.

Pain Management

Cryotherapy is a painful procedure, especially for large keloids. Pain is the most critical limiting factor in using cryotherapy to treat keloids. The degree of discomfort and pain from cryotherapy depends on the location and size of the keloid. Cryotherapy of small keloids, measuring up to half an inch (1.25 cm) in diameter, although it can cause some pain, the discomfort is fairly manageable and often does not require anything. Keeping busy and distracted for several hours after treatment is all that is needed to manage the discomfort of treating small keloids. If needed, patients with small size keloids can often take Tylenol or Ibuprofen to manage minor pain resulting from cryotherapy treatment. Treatment of keloids that are larger than half an inch (>1.25 cm) will naturally cause more discomfort and more pain – something that will require further attention and proper management. Naturally, the larger the keloid is, the intensity of the cryotherapy pain will be more.

Another thing to keep in mind is that the pain from cryotherapy is short-lived and often subsides within 8-12 hours. The peak intensity of the pain occurs 1-2 hours after the procedure. A simple local anesthetic may be all that some patients will need to overcome this pain. However, as the pain tolerance is variable among individuals, some patients will need to take acetaminophen, Ibuprofen, or even codeine for pain control.

Application of cryotherapy to lesions that are larger than one inch in diameter requires proper planning and adequate pain control measures. Although larger doses of narcotic pain medications can help with managing the pain, a better alternative to oral pain medicines is the usage of a new medication called "Exparel" to induce local anesthesia. Regular local anesthetics provide pain relief that usually wears off in about an hour after cryotherapy. However, Exparel once injected into the skin will induce durable anesthesia, with effects lasting up to three days. Despite the proper usage of this medicine, some patients will still encounter some pain that will need to be properly managed.

During your consultation, Dr. Tirgan will advise you on how much pain you may expect, depending on the unique type, size and location of your keloids. He will also provide you with a proper pain management plan for your particular type of keloid.

What Happens Afterwards:

After the application of cryotherapy, treated keloid and the surrounding skin will swell up to form a large blister that often grows to twice the size of the keloid or larger. It is best to use cotton gauzes and paper tapes to cover and bandage the treated areas for the next few days after treatment. The swollen keloid will gradually ooze and leak yellowish and at times blood-tinged fluid. The amount of swelling and oozing depends on the size of the treated keloid; this continues for 5-7 days, at which point the keloid tissue starts to dry out and form a dark or black color scab. From this point on, and over the next few weeks, the keloid will gradually become drier, transforms into a black color scab, and gradually contracts and reduces in its size.

Two to three weeks later, the edges of the scab will start to separate from the underlying skin. Once the scab is completely separated, it will fall off completely. This usually happens about 4-6 weeks after the application of cryotherapy. You should not force the separation of scab from the keloid. The site of treated keloid should be kept clean and dry. Using a Q-tip or cotton swabs, clean the edges of the keloid, and also clean the areas where the keloid comes in contact with normal skin. Gently dip the Q-tip in a small amount of water, gentle soap water, Hydrogen Peroxide or Iodine Solution to clean the edges of a keloid. It is also very important for patients not to scratch or irritate the treated keloid. Treated areas can be washed as usual. Shaving blades should not be used over or near the treated keloid.

Most patients return to the office after the scab comes off. This is when the keloid is ready for the next treatment. Sometimes, the patients may need to return to the office within a few days, or a week after cryotherapy, to assess the impact and efficacy of treatment. Dr. Tirgan will advise you about this during your consultation visit.

Once the scab falls off, the keloid is considerably smaller and is ready for the next treatment. Most keloids need 2-to-3 treatments to achieve desirable results. After the scab falls off the underlying skin will appear pink and without any pigments. Skin color will gradually normalize over time; the normalization process is variable and may take several months.

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